Critical Care Quiz 1 : Midcourse Study Plan

Which type of support provides immediate relief to the client with tongue occlusion, loss of gag reflex, alterations in level of consciousness, oxygen (O 2) saturation of 40 mm Hg, and carbon dioxide (CO 2) saturation of 75 mm Hg? A. Tracheotomy B. Laryngeal repair C. Abdominal thrust maneuver D. Autotitrating positive airway pressure

A. Tracheotomy

The nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? A. Deep breathing B. Hoarse quality to the voice C. Pink-tinged, frothy sputum D. Rapid abdominal breathing

B. Hoarse quality to the voice

Which client in the emergency department would the nurse assess first? A. Client with chest pressure and ST segment elevation on the electrocardiogram B. Client who reports a sharp chest pain with deep inspiration for the past week C. Client who has history of heart failure with ascites and bilateral 4+ ankle swelling D. Client with palpitations and paroxysmal atrial fibrillation at a rate of 136 beats/minute

A. Client with chest pressure and ST segment elevation on the electrocardiogram

When the nurse initiates continuous cardiac monitoring and maintains oxygen saturation and end-tidal carbon dioxide on a client who survived a fire, which type of emergency assessment is being performed? A. Focused adjuncts B. Full set of vital signs C. Comfort measures D. Family presence

A. Focused adjuncts

Which interventions upon admission to the emergency unit would be beneficial for the client who survived a lightning strike? Select all that apply. One, some, or all responses may be correct. A. Administration of diphenhydramine B. Applying spinal immobilization technique C. Stabilization of ABCs—airway-breathing-circulation D. Applying ice packs in the axillae and groin and on the neck and head E. Rapid rewarming in a water bath at a temperature range of 104°F to 108°F (40°C-42°C)

B. Applying spinal immobilization technique C. Stabilization of ABCs—airway-breathing-circulation

Which problem would be the most difficult for the nurse to manage when meeting the needs of an extensively burned client 3 days after admission? A. Weaning of potent opioids like morphine for severe pain to prevent addiction B. Changing and debriding wounds to prevent infection C. Beginning a discussion related to alteration in body image D. Turning and positioning the client every 30 to 60 minutes to prevent contracture development

B. Changing and debriding wounds to prevent infection

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. Which action will the nurse take first? A. Remove the client's clothing. B. Evaluate whether the client has inhaled smoke. C. Insert a venous access device in an unaffected arm. D. Determine the extent of the burns, using the rule of nines.

B. Evaluate whether the client has inhaled smoke.

Which action would the nurse do immediately when the nurse finds the respiratory rate is 8 breaths per minute in a client who is on intravenous morphine sulfate? A. Measure other vital signs. B. Stop administering the medication. C. Elevate the head of the client's bed. D. Report to the primary health care provider.

B. Stop administering the medication.

During the postoperative period after receiving a kidney transplant, the client's creatinine level is 3.1 mg/dL (260 mmol/L). Which action would the nurse implement first in response to this laboratory report? A. Notify the primary health care provider. B. Obtain current blood test results. C. Assess for decreased urine output. D. Check the intravenous (IV) infusion.

C. Assess for decreased urine output

A client is en route to the emergency department after sustaining a gunshot wound to the chest. Which priority nursing action would the nurse take to prepare for the arrival of the client? A. Reserve an operating room. B. Organize equipment for a tracheotomy. C. Prepare equipment for chest tube insertion. D. Arrange for a portable chest x-ray examination.

C. Prepare equipment for chest tube insertion.

The client being treated in the emergency department with which pain medication must be placed on electrocardiogram equipment? A. Aspirin B. Methadone C. Butorphanol D. Naproxen

D. Naproxen

Based on the information in the chart of a client who has emphysema and is recovering from an acute myocardial infarction, which prescribed medication would the nurse consider the priority at this time? Laboratory Test Results WBC: 10,000 mm° (10 x 10°/L) Hemoglobin: 11 gm/dL (110 mmol/L) Hematocrit: 34% INR: 2.5 Vital signs Temperature: 100 °F (37.8 °C) Pulse: 100 beats/min, regular rhythm Respirations: 24 breaths/min Blood pressure: 176/96 mm Hg Physical assessment Using pursed lip breathing Pulse bounding Face appears flushed Reports a headache and dizziness A. Albuterol B. Warfarin C. Metoprolol D. Acetaminophen

C. Metoprolol

A nurse is evaluating a client's fluid loss resulting from extensive burns. Which laboratory result will the nurse check? 1 Blood urea nitrogen (BUN) 2 Sedimentation rate 3 Hematocrit (Hct) 4 Blood pH

3 Hematocrit (Hct)

A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which nursing intervention would be included in the plan of care when providing wound care for this client? A. Use a consistent approach to care and encourage participation. B. Prepare equipment while doing the procedure and explain the treatment to the client. C. Rinse the burn area with 105°F (40.6°C) water to prevent loss of body temperature. D. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done.

A. Use a consistent approach to care and encourage participation.

A client develops bacterial meningitis. Which action is the priority nursing care? A. Monitoring for signs of intracranial pressure B. Adding pads to the side of the bed C. Administering prescribed antibiotics D. Administering glucocorticoids

C. Administering prescribed antibiotics

Which action by the nurse is best when a client who had a myocardial infarction 2 days previously has a temperature of 100.2°F (37.9°C)? A. Auscultate the chest for diminished breath sounds. B. Encourage coughing and deep breathing every hour. C. Record the temperature reading and continue to monitor it. D. Suspect an infection and notify the health care provider immediately.

C. Record the temperature reading and continue to monitor it.

A client in the emergency department presents with signs and symptoms indicative of an opioid overdose. Which medication would the nurse anticipate administering? A. Naloxone B. Methadone C. Epinephrine D. Amphetamine

A. Naloxone

The nurse is caring for a client who had a skin graft applied over a full-thickness burn on the chest. Which observation of the donor site during the first 24 hours after surgery would the nurse report to the primary health care provider immediately? A. Small amount of yellowish-green oozing B. Moderate area of serosanguineous oozing C. Epithelialization under the nonadherent dressing D. Separation of the edges of the nonadherent dressing

A. Small amount of yellowish-green oozing

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. Which action would the nurse take? A. Assess for obstructions in the chest tube. B. Increase the amount of continuous suction. C. Add sterile water to the water-seal chamber. D. Make preparations to remove the chest tube.

A. Assess for obstructions in the chest tube.

Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction? A. Stop the blood transfusion immediately. B. Report to the primary health care provider. C. Recheck identifying tags and numbers on the client. D. Maintain a patent intravenous (IV) line with saline solution.

A. Stop the blood transfusion immediately.

Which clinical finding would the nurse anticipate regarding the alveoli in the lungs of a neonate born at 28 weeks' gestation? A. They have a tendency to collapse with each breath. B. There usually is a sufficient supply of pulmonary surfactant. C. Although apparently mature, they cannot absorb adequate oxygen. D. Oxygen is not released into the circulation because they overinflate.

A. They have a tendency to collapse with each breath.

Which nursing action has the highest priority when caring for a client who has had an acute myocardial infarction (MI)? A. Prevent nausea and vomiting. B. Monitor for cardiac dysrhythmias. C. Use prescribed medication to lower fever. D. Teach about the phases of cardiac rehabilitation.

B. Monitor for cardiac dysrhythmias.

Which is the priority focus of nursing care for a client with a spinal cord injury during the immediate postinjury period? A. Inhibiting urinary tract infections B. Preventing contractures and atrophy C. Avoiding flexion or hyperextension of the spine D. Preparing the client for vocational rehabilitation

C. Avoiding flexion or hyperextension of the spine

The nurse notes blood pressure of 200/110 mm Hg and swelling of the operative leg for a client who has had a femoropopliteal bypass graft. Which action would the nurse take next? A. Evaluate the client's orientation. B. Check pedal pulses distal to the graft. C. Notify the client's health care provider. D. Monitor blood pressure every 15 minutes.

C. Notify the client's health care provider.

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching, seizures, cyanosis, abnormal respirations, and a short, shrill cry. Which complication would the nurse suspect? A. Tetany B. Spina bifida C. Hyperkalemia D. Intracranial hemorrhage

D. Intracranial hemorrhage